ROUSSO FACIAL PLASTIC SURGERY CLINIC, P.C.

CONSULTATION AN]) MEDICAL HISTORY

Name____________________________________________ Date of Birth_________________ Today’s Date_________________

Address: Home

BusinessStreet City State Zip telephone

Marital Status: 5, M, D, W, Spouse’s Name_____________________________________________________________________

Your Occupation/Employer Spouse’s Occupation/Employer

How were you referred to us?_________________________________ Name of family members who are our patients

In which surgical procedgre (s) are you interested in? (Please )

Facelift Rhinoplasty Chin Eyelids

Septoplasty Chemical Peel Dennabrasion Laser Resurfacing

Microdermabrasion Scar Revision Protruding Bars Hair Transplants

Laser Hair Removal Botox Injection Facial Reconstruction Removal of Cyst, Warts, Moles

Removal of Brown Spots Removal of Facial Veins Micro Laser Peel Restylane/SculptralRadies

Other

When did you begin to consider surgical correction? Why have you decided to have it done at this point in time?

Have you consulted any other doctor about this? Y N When?_________________________________________________________

Have you discussed this surgery with your family? Yes ________No_________ Are they agreeable? Yes No_________

Have you had any previous cosmetic, plastic or reconstructive surgery? Y N When, and what, if anything was done?___________

‘Who performed the surgery? Where was it performed? Were you satisfied with the results? Y N

If not why?

If injury, describe injury?

Date of injury?_____________________ Place of injury? Treatment r~ceived?

Do you have problems breathing through your nose? Y N Do you have sinus problems? Y N

Have you had nasal trauma? Y N When? _______________________ Describe:________________________________________

Has anyone in your family or a close friend had cosmetic, plastic or reconstructive surgery? Y N‘What was done? _________________________________ By ‘Whom? ________________________________________________

Have you had any other prior surgery? Y N When was it performed? Head & Neck _________________________________

Skin _________________________Teeth/Gums _______________________Chest Abdomen_______________Reproductive system BacklAths/Legs Other______________________________________

Did you have a normal recovery? Y N Did the results meet your expectations? Y N

If no explain

‘Who is your primary physician? Telephone

Address _______________________________________________________City____________________________ State__________________

May we have your permission to consult with your physician? Y ~N

(over)

Street City State Zip telephone

Cell Phone:_____________________________________ Email Address:_________________________________________

MEDICAL HISTORY ( ppropriate response)

No Yes Are you now taking any drugs or medications? (How often?)List them if you can___________________________________________

No Yes Are you allergic to any medication, cream, tape, make-up, etc?List them if you can_____________________________________________________________

No Yes Have you ever received local anesthesia (“Novocaine, Xyloeaine”) by a dentist or doctor?No Yes Did you have a “reaction” to any anesthesia? Explain__________________________________________No Yes Do you or any family members have:(indicate who)

Heart trouble Excessive bleeding tendencies_____________________High BloodPressureDiabetes_________________________________________Thyroid Problems Psychiatric or “nerve” problems___________________Excessive bruisability Excessive Scarring_____________________________Delayed or poor healing Other______________________________________

No Yes Do you have any history of bleeding: (indicate which)From the nose In the Urine Vomiting blood________________From the rectum Coughing up Blood Other:____________________

No Yes Do you have or have you had any problems with your eyes or vision? Explain_____________________No Yes Has a doctor ever said you had “heart trouble”? Explain_________________________________________No Yes Do you have “stomach trouble” or ulcers? Explain_____________________________________________No Yes Do you have or have you had chest or lung problems? Explain____________________________________No Yes Have you ever had liver, gall bladder trouble or “yellowjaundice? Explain_________________________No Yes Have you been bothered by kidney or bladder problems? Explain________________________________No Yes Do you have frequent skin infections, irritation or rashes? Explain_______________________________No Yes Have you ever had fever blisters or “cold sores” or Canker sores on your face, lips or in your Mouth or

Genital Herpes? Explain______________________________________________________________No Yes Do you often have severe headaches or dizzy spells? Explain____________________________________No Yes Has any part ofyour body ever been paralyzed or numb? ExplainNo Yes Did you ever have a convulsion or seizure? Explain____________________________________________No Yes Were you ever told you had any venereal disease or AIDS? Explain_________________________________No Yes Were you ever treated for anemia or any problems with your blood? Explain_______________________No Yes Have you ever taken hormones or thyroid medication? ExplainNo Yes Do you smoke?No Yes Do you drink two or more alcohol drinks per day?No Yes Have you ever received treatment for abuse of alcohol or drugs? Explain__________________________No Yes Do you often get depressed? -

No Yes Have you ever received medical treatment for a “nervous breakdown”? Explain_____________________No Yes Have you ever been under the care of a psychiatrist or psychologist? Explain_______________________

No Yes Do you have any other medical problems that have not been covered? Explain____________

No Yes Do you accept the fact that every medical and surgical treatment is associated with risks andImponderables?

No Yes Do you have an Advanced Directive?

Signed_________________________________________________________ Date_______(Patient)

Reviewed By:_________________________________________ Date______(Physician)

The information you have provided is essential in our comprehensive evaluation in your case.

Thank You,ROUSSO FACIAL PLASTIC SUR5JRY CLINIC, P.C.

No Yes Do you have or have you had nasal allergies, “sinus problems”, asthma or hay fever? (Explain below)

ROUSSO FACIAL PLASTIC SURGERY CLINICMEDICATION RECONCILIATION FORM~

DISCONTINUED MEDICATIONS/PRODUCTS (DUE TO ALLERGIES, SIDE EFFECTS OR REACTIONS)

CURRENT MEDICATIONS(Include all Herbal Supplements,Vitamins & OTC)

DOSE

NEW MEDICATIONS PRESCRIBED

DATE Medication Dosage Given By

NAME Date of Birth Chart if Reviewed By: Date:

ALLERGIES — Medication/Food/Environmental Side Effects, Reaction or Intolerance Experienced(Symptoms/Severity)

FREQUENCY INDICATION(Reason for Taking)

sso Facial Plastic Surgery Clinic,The Mountain Brook Center

2700 Highway 280 Suite 300 WBirmingham, Alabama 35223

(PATIENT INFORMATION)

Today’s DateNameAddressCity______________ State____ ZipPhone: Home _____________________

Business ____________________

Date of Birth________Height WeightSocial Security # _______________________

Insurance Carrier_____________________Contract Number___________________Insured’s Name on Card________________Insured’s Date of Birth________________Person Responsible for Bill_______________

Date:__________________________Examination, History, Photos, Procednre(s) &Recommendations:

PATIENT WORKSHEET

I (FOR OFFICE USE ONLY)

Sex(1~4) (F)

(O\ ~.ZJ9Ye’ ‘1’

1% t

ROUSSO FACIAL PLASTIC SURGERY CLINIC P.C.Daniel E. Rousso, M.D.

2700 HWY 280, Suite 300-WBirmingham, AL 35223

PATIENT CONSENT TO LEAVE PHONE MESSAGE[JNFORMATION

Patient Name frrint)

Dr. Daniel E. Rousso has adopted a policy that. requires their staff to obtain authorization from thepatient to leave detailed messages for the patient. This policy is to protect the patient and to also protectthe employees of Rousso Facial Plastic Surgery Clinic from violating apatient’s confidentiality. If anemployee of Rousso Facial Plastic Surgery Clinic does not have a signed consent on file, the staff mayonly leave their first name with a brief message, e.g. “I am calling to remind you that you have a doctorappointment tomorrow at 9:00 AM”.

By completing the consent below, you hereby authorize the staff to call and leave their name, theprovider’s name (Daniel E. Rousso, M.D.), and additional information on an answering machine, cellphone or at your place of work. Unless notified in writing, this consent will remain in effectpermanently.

I give consent to Dr. Rousso and/or his staff to leave a message regarding appointments or other.necessary information.

Please print phone numbers on line(s):

1. Onanswering machine at home

2. On cell phone voice mail

3. . On voicemail at work

4. ______________________________Sendyou an email (please write in email address if Ok)

Patient Signature Date

I do NOT consent to ~y messages being left.

Patient Signature Date

Rousso Facial Plastic SurgeryAesthetic Medical Spa

HIPPA Notice of Privacy Practices

Acknowledgement of Receipt

I, ________________________________, have received the Notice of Privacy formfrom Rousso Facial Plastic Surgery Clinic.

Date:

In lieu of patient signature, Imember of Rousso Facial Plastic Surgery Clinic, state that patient,

Practices form.

a staff

has been given our current Notice of Privacy

Date:

ROUSSO FACIAL PLASTIC SURGERYPatient Authorization for Payment and Authorization to Release Information

Authorization for Payment

I certif~’ that theinformation provided by me is correct. I authorize ity insurance company (ies)

to fhrnish any agent of Rousso Facial Plastic Surgery any and all information pertaining to my

insurance beneflts and status of claims submitted by Rousso Facial Plastic Surgery. I authorize

payment directly to Rousso Facial Plastic Surgery for Medicare benefits (as applicable) and other

insurance benefits otherwise payable to me. In the event that my insurance carrier does not

accept ‘assignment of benefits’, or any other payment are sent directly to me, I will hold them in

trust for Rousso Facial Plastic Surgery for payment of my bill..I understand that I can make

payment for sérviceby either personpl check or by endorsing the insurance payment by writing

‘Pay to the order of’ Rousso Facial Plastic Surgery and my signature.

I understand that I am responsible to Rousso Facial Plastic Surgery for any/all charges not paid

by a third party, including any co-payments, deductibles, or charges for non-covered services,

except where program requirements or contractual agreements hold me harmless

Authorization to Release Information

I consent to the release of information and/or disclosure to Rousso Facial Plastic Surgery of all or

any part ofm~1 medical record by any physician, hospital, or other facility ofwhich I have been a

patient; and release of information by Rousso Facial Plastic Surgery to individuals acting in

official capaoities as my advocate, representing governmental or third party payers,

governmental agencies, accrediting bodies, or other health care providers involved in my care

including any successors ofRousso Facial Plastic Surgery.

Signature:____________________________ Date:_______ Patient Name: -_________________

Patient or Authorized Representative Signature Applicable only if Authorized Representative signs for Patient

Signature: ____________________________________ Date: ______—

Party Accepthg Responsibility for Payment (on Patient’s behalO ifapplicable Relationship to Patient

Rousso Facial~Plastic Surgery Representative (as witness): _____________

Date: ___________________

For Translations:

This document was translated to patientfauthorized representative into

language prior to signature and any questions were answered.

Translated By (Signature/Title):Date: